Detailed Information

NPI Number 1750448791 has the “Organization” type of ownership and has been
registered to the following primary business legal name (which is a provider name or healthcare organization name) — STATCARE, LLC .
The enumeration date of this NPI Number is 01/02/2007.
NPI Numer information was last updated at 07/19/2013.

Provider's other registered legal business name is STATCARE URGENT CARE CLINIC .

The provider is physically located (Business Practice Location) at:

9525 CLIFFDALE RD.
FAYETTEVILLE
, NC
28304
US

The provider can be reached at his practice location using the following numbers:

Phone 910-826-7925Fax 910-864-7925

The provider's official mailing address is:

P.O. BOX 87707
FAYETTEVILLE
, NC
28304
US

The contact numbers associated with the mailing address are:

Phone 910-826-7828Fax 910-864-7925

The authorized official registered with the “1750448791” NPI Number
is
DR.
RAJU
B
RAVAL
.

The authorized official title (position) is MEDICAL DIRECTOR.

You can reach the authorized official at the following phone number 910-826-7828.

Scope of Practice

The following information about the specialty of the provider is available:

#

Taxonomy Code

Taxonomy

License Number

License Number State

1

207R00000X

Internal Medicine

9700722

NC

Legacy Identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

The "Is the organization a subpart?" question must be answered. If the organization is a subpart, the Parent Organization Legal Business Name (LBN) and Parent Organization Taxpayer Identification Number (TIN) fields must be completed. The Parent Organization LBN and TIN fields can only be completed if the answer to the subpart question is Yes.
Many organization health care providers who apply for NPIs are not legal entities themselves but are parts of other organization health care providers that are legal entities (the "parents").
Here are three examples of organization health care providers that may be considered subparts and may apply for NPIs if so directed by their "parents":
(1) The psychiatric unit in a hospital is not a legal entity but is part of the hospital (the "parent"), which is a legal entity. The legal entity must obtain an NPI. The psychiatric unit is an example of a subpart that could have its own NPI if the hospital determines that it should.
(2) A group practice that is not a sole proprietorship has a main location and could have other offices in different locations, but each office is not a separate legal entity; instead, each office is part of the corporation (the "parent") which is a legal entity. The offices are examples of subparts that could have their own NPIs if the main location determines that they should.
(3) A pharmacy fills prescriptions for patients whose physicians have prescribed medications for them and may also rent or sell durable medical equipment to patients whose physicians have ordered such equipment for them. Neither the pharmacy line of business nor the DME line of business represent legal entities; instead, both lines of business are part of an organization (the "parent") that is a legal entity. Each line of business represents a different Healthcare Provider Taxonomy or area of specialization that often submits its own electronic claims to health plans.
The "parent"-we don't know who the parent is in this example-must ensure that each subpart that submits its own claims to health plans has its own NPI.

4

Provider Organization Name (Legal Business Name)

STATCARE, LLC

Provide organization name (legal business name used to file tax returns with the IRS). The Organization Name field allows the following special characters: ampersand, apostrophe, "at" sign, colon, comma, forward slash, hyphen, left and right parentheses, period, pound sign, quotation mark, and semi-colon. A field cannot contain all special characters.

The first line mailing address of the provider being identified. This data element may contain the same information as ''Provider first line location address''.

8

Provider Business Mailing Address City Name

FAYETTEVILLE

The City name in the mailing address of the provider being identified. This data element may contain the same information as ''Provider location address City name''.

9

Provider Business Mailing Address State Name

NC

The State or Province name in the mailing address of the provider being identified. This data element may contain the same information as ''Provider location address State name''.

10

Provider Business Mailing Address Postal Code

28304

The postal ZIP or zone code in the mailing address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available. This data element may contain the same information as ''Provider location address postal code''.

11

Provider Business Mailing Address Country Code

US

The country code in the mailing address of the provider being identified. This data element may contain the same information as ''Provider location address country code''.

12

Provider Business Mailing Address Telephone Number

910-826-7828

The telephone number associated with mailing address of the provider being identified. This data element may contain the same information as ''Provider location address telephone number''.

13

Provider Business Mailing Address Fax Number

910-864-7925

The fax number associated with the mailing address of the provider being identified. This data element may contain the same information as ''Provider location address fax number''.

14

Provider First Line Business Practice Location Address

9525 CLIFFDALE RD.

The first line location address of the provider being identified. For providers with more than one physical location, this is the primary location. This address cannot include a Post Office box.

15

Provider Business Practice Location Address City Name

FAYETTEVILLE

The city name in the location address of the provider being identified.

16

Provider Business Practice Location Address State Name

NC

The State or Province name in the location address of the provider being identified.

17

Provider Business Practice Location Address Postal Code

28304

The postal ZIP or zone code in the location address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available.

18

Provider Business Practice Location Address Country Code

US

The country code in the location address of the provider being identified.

19

Provider Business Practice Location Address Telephone Number

910-826-7925

The telephone number associated with the location address of the provider being identified.

20

Provider Business Practice Location Address Fax Number

910-864-7925

The fax number associated with the location address of the provider being identified.

21

Provider Enumeration Date

01/02/2007

The date the provider was assigned a unique identifier (assigned an NPI).

22

Last Update Date

07/19/2013

The date that a record was last updated or changed.

23

Authorized Official Last Name

RAVAL

The last name of the person authorized to submit the NPI application or to change NPS data for a health care provider.

24

Authorized Official First Name

RAJU

The first name of the authorized official

25

Authorized Official Middle Name

B

The middle name of the authorized official

26

Authorized Official Title or Position

MEDICAL DIRECTOR

The title or position of the authorized official

27

Authorized Official Name Prefix Text

DR.

Authorized Official Name Prefix Text

28

Authorized Official Credential Text

D.O.

Authorized Official Credential Text

29

Authorized Official Telephone Number

910-826-7828

The 10-position telephone number of the authorized official.

30

Healthcare Provider Taxonomy Code #1

207R00000X

The Health Care Provider Taxonomy code is a unique alphanumeric code, ten characters in length. The code set is structured into three distinct "Levels" including Provider Type, Classification, and Area of Specialization.

31

Healthcare Provider Taxonomy 1

Internal Medicine

Healthcare Provider Taxonomy #1

32

Provider License Number 1

9700722

Certain taxonomy selections will require you to enter your license number and the state where the license was issued. Select Foreign Country in the state drop down box if the license was issued outside of United States. The License Number field allows the following special characters: ampersand, apostrophe, colon, comma, forward slash, hyphen, left and right parentheses, period, pound sign, quotation mark, and semi-colon. A field cannot contain all special characters. DO NOT report the Social Security Number (SSN), IRS Individual Taxpayer Identification Number (ITIN) in this section.

33

Provider License Number State Code 1

NC

Provider License Number State Code #1

34

Healthcare Provider Primary Taxonomy Switch 1

Y

Primary Taxonomy:

X - The primary taxonomy switch is Not Answered;

Y - The taxonomy is the primary taxonomy (there can be only one per NPI record);

N - The taxonomy is not the primary taxonomy.

35

Other Provider Identifier 1

5903128

Other Provider Identifier #1

36

Other Provider Identifier Type 1

MEDICAID

Other Provider Identifier Type #1

37

Other Provider Identifier State 1

NC

Other Provider Identifier State #1

38

Other Provider Identifier 2

027AU

Other Provider Identifier #2

39

Other Provider Identifier Type 2

OTHER

Other Provider Identifier Type #2

40

Other Provider Identifier State 2

NC

Other Provider Identifier State #2

41

Other Provider Identifier Issuer 2

BCBS

Other Provider Identifier Issuer #2

42

Other Provider Identifier 3

G15059

Other Provider Identifier #3

43

Other Provider Identifier Type 3

MEDICARE UPIN

Other Provider Identifier Type #3

44

Other Provider Identifier State 3

NC

Other Provider Identifier State #3

45

Healthcare Provider Taxonomy Group 1

193200000X MULTI-SPECIALTY GROUP

Healthcare Provider Taxonomy Group 1

46

Healthcare Provider Taxonomy Group Description 1

Multi-Specialty Group - A business group of one or more individual practitioners, who practice with different areas of specialization.